Provider Demographics
NPI:1093792913
Name:ROSENGARTEN, JEFFREY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LEE
Last Name:ROSENGARTEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 772555
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-2555
Mailing Address - Country:US
Mailing Address - Phone:314-238-5260
Mailing Address - Fax:314-821-1833
Practice Address - Street 1:1800 HOLLISTER DR
Practice Address - Street 2:SUITE G-18
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5263
Practice Address - Country:US
Practice Address - Phone:847-918-1462
Practice Address - Fax:847-968-4311
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ436812085R0202X
OH35.0911262085R0202X
KY407612085R0202X
WV226382085R0202X
VA01012407302085R0202X
WI28696-0202085R0202X
IN01058962A2085R0202X
IL036080130-52085R0202X
WI286962085R0202X
IL0360801302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202926OtherGROUP PTAN
IL212545OtherGROUP PTAN
IL036080130Medicaid
WI34174800Medicaid
ILL61852Medicare PIN
ILL93765Medicare PIN
IL212545021Medicare PIN
IL202926OtherGROUP PTAN
ILF07877Medicare UPIN
IL212545OtherGROUP PTAN
ILK06061Medicare PIN
ILK28486Medicare PIN
ILK45890Medicare PIN
ILK22468Medicare PIN
ILL96905Medicare PIN